Project: Ghana Emergency Medicine Collaborative Document Title: Approach to Bradycardias and Tachycardias Author(s): Rockefeller Oteng (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact [email protected]with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
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GEMC- Approach to Bradycardias and Tachycardias-for Residents
This is a lecture by Rockefeller Oteng from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
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Project: Ghana Emergency Medicine Collaborative Document Title: Approach to Bradycardias and Tachycardias Author(s): Rockefeller Oteng (University of Michigan), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/
We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact [email protected] with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
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Bradycardia
James Heilman, MD, Wikimedia Commons 3 3
- Prepare for transcutaneous pacing
- Consider atropine
- Consider epinephrine or dopamine
Signs or symptoms of poor perfusion caused by the bradycardia? (e.g. acute altered mental status, ongoing chest pain, hypotension, or other signs of shock?
Brady-‐ Arrhythmias
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BRADYCARDIA Heart Rate <60 bpm
and inadequate for clinical condition
- Maintain patient airway; assist breathing as needed
- Give oxygen - Monitor EKG (id rhythm),
blood pressure, oximetry - Establish IV access
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Observe/Monitor 4A
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- Prepare for transvenous pacing
- Treat contributing causes
- Consider expert consultation 5
REMINDERS - If pulseless arrest, go to pulseless arrest algorithm - Search for and treat possible contributing factors:
• If pulseless arrest develops, go to pulseless arrest algorithm • Search for and treat possible contribuHng factors: Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypo/hyperkalemia Hypoglycemia Hypothermia
tachycardia, ectopic junctional tachycardia, and non-paroxysmal junctional tachycardia.
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SVT – Mechanism
SVT -‐ Treatment • Adenosine:
– 6 mg - termination in 60-80% – 12 mg - termination in 90-95% – Contraindicated in heart transplant, COPD/asthma, and wide complex
tachycardia (unless 100% certain is SVT w/ aberrancy) – Avoid with evidence of pre-excitation
• Beta blockers or Ca++ channel blockers - contraindicated in antidromic WPW • Last resort: procainamide, ibutilide, propafenone, or flecainide • If unstable - electricity!
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SVT -‐ Treatment w/ Adenosine
Displaced, Wikimedia Commons 14 14
A\er Adenosine
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- Likely reentry SVT * Observe for recurrence * Treat recurrence with adenosine, diltiazem, B-blockers
- Likely A. flutter, ectopic atrial tachycardia, or junctional tachycardia
- Consider diltiazem and B-blockers to control HR
- Treat underlying cause - Consider expert consult
Converts Does Not Convert
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Stable and Wide Regular or Irregular?
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WIDE QRS -> is rhythm REGULAR? 12
Wide QRS
- If V. tachycardia or uncertain rhythm:
* Amiodarone * Synchronized cardioversion - If SVT with aberrancy: * Adenosine (Box 7)
- If A. fibrillation with aberrancy: * See Box 11 - If pre-excited A. fibrillation: * Expert consult advised * Avoid adenosine, digoxin, diltiazem, verapamil * Consider amiodarone - If recurrent polymorphic VT: * Seek expert consult - If torsades de pointes: * Give magnesium
Regular Irregular
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Wide Complex Tachycardia
Afib with LBBB Steven Fruitsmaak, Wikimedia Commons 17 17
Wide Complex Tachycardia • Stable
– Amiodarone 150 mg over 10 min or other anti-arrhythmics – Prepare for synchronized cardioversion
• Unstable – ABC’s/Call for help/Start CPR – Defibrillate: Biphasic 120-200 J (When in doubt pick 200 J),
monophasic 360 J – Epinephrine 1 mg IV q3-5 min – Vasopressin 40 Units IV – May try amiodarone or lidocaine after 3 attempts at defibrillation
• Amiodarone 300 mg, may repeat w/ 150 mg x1 • Lidocaine 1-1.5 mg/kg, then 0.5-0.75 mg/kg, max is 3 mg/kg
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H’s and T’s
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Treat contribuHng factors: Hypovolemia Hypoxia
Hydrogen ion (acidosis) Hypo/hyperkalemia Hypoglycemia
Hypothermia
During EvaluaHon
• Secure, verify airway and vascular access when possible